Director of Clinical Effectiveness at AdventHealth

Date Posted: 8/31/2020

Job Snapshot

  • Job Schedule
  • Date Posted:
  • Job ID:
  • Job Family
    Quality/Clinical Effectiveness
  • Travel
    Yes, 25 % of the Time
  • Shift
    1 - Day

Job Description

Director of Clinical Effectiveness

AdventHealth Palm Coast
Location Address: 60 Memorial Medical Parkway, Palm Coast, FL
Top Reasons To Work At AdventHealth Palm Coast
  • Great benefits such as: Educational Reimbursement
  • Career growth and advancement potential
Work Hours/Shift:

You Will Be Responsible For:

•         Responsible for overseeing the daily operations of the departments, including: Clinical Effectiveness, Performance Improvement, Risk Management, Infection Control, and Education. 

•         Interviews, hires, evaluates, disciplines and terminates staff as appropriate

•         Prepares and manages annual budgets which assures necessary staffing, equipment and supplies

•         Maintains up-to-date departmental and program plans, job descriptions, policy and procedures, protocols and guidelines

•         Provides opportunities to update and educate staff in work-related areas. Maintains high levels of employee engagement and job performance by providing recognition and opportunities for learning.

•         Ensures departmental compliance with hospital policy and procedure

•         Acts as a liaison to administration, medical staff, departments and committees in all aspects related to the departments’ responsibilities

•         Assures feedback and reporting of information to all appropriate parties internally and externally

•         Coordinates and attends meetings as needed.

•         Collaborate with multidisciplinary team to implement evidence based practice and national guidelines into patient care protocols and clinical practice ongoing

•         Assist in the development, implementation, education, evaluation, and revision of  patient clinical pathways and policies and procedures related to clinical improvement and effectiveness. .  

•         Establishes and directs the collection, analysis and presentation of all data for all areas of Performance Improvement. 

•         Directs the coordination of Physician Peer Review, Ongoing Professional Practice Evaluation, and Focused Practice Evaluation for the Medical Staff. 

•         Collaborates with legal council and medical staff office to regarding ongoing review and maintaining medical staff bylaws to current standards. 

•         Directs the collection of accurate data and submission of data to comparative databases by defined due dates, e.g., Corporate Indicators, Premier data, Core Measures, CMS Quality Projects, etc.

•         Directs and ensures compliance with TJC ORYX Core Measure program through contracting with performance measurement systems and determining appropriate indicator data submission.

•         Develops the process for utilization of information systems to provide outcomes management data to support the overall quality program, e.g., APR-DRG, Physician Quality Focus, Premier, Trendstar, Med QM, etc.

•         Analyzes statistical and clinical data to identify opportunities for improvement in various processes and disease entities.

•         Directs the hospital-wide Performance Improvement Program, including PI education, collection and use of comparative data, implementation and effectiveness of Departmental Key Quality Indicators (KQI’s), initiation, facilitation and effectiveness of PI Teams

•         Directs the coordination of the Clinical Best Practice program &Patient Safety initiatives

•         Develops strategies for clinical improvement that results in improvement on the clinical close

•          Provides ongoing education regarding Performance Improvement, clinical regulatory changes and patient safety to Medical Staff, Hospital staff and management.

•         Provides “just-in-time” training to PI Teams in PI tools, techniques and methods

•         Provides assistance to departments in prioritizing and implementing performance improvement projects. .

•         Provides assistance to departments, PI Teams and Medical Staff in identifyingbenchmarks or comparative data sources for PI measures.

•         Ensures that appropriate action is taken in response to identified opportunities for improvement.

•         Acts as liaison between the hospital and the CMS Quality Improvement Organization.

•         Ensures that an effective Infection Control Program is implemented in the organization

•         Ensures accurary in reporting to external agencies regarding Infection Control

•         Oversees clinical improvement regarding identified Infection Control trends

•         Oversees the education department providing education and training, in-services, orientation, and internship programs to hospital personnel in a manner that encourages high quality patient care, safe environment, and job satisfaction.

•         Oversees the system for identification and analysis of loss or injury exposure in coordination with the Director of Risk.  . 

•         Oversees loss prevention activities in coordination with Risk Management. 

•         Coordinates claims control.

•         Establishes goals and objectives for program implementation and the Education Department on the whole in conjunction with Education Department Manager. Goals and objectives are developed from annual needs survey, organization vision, meetings with Department Managers and Directors, reviews of aggregate data, medical staff feedback, and regulatory agency requirements.  Develops staff education based on goals and objectives, and cooperates with organization-wide departments for programs as directed.

•         Consults with Director of Human Resources and Executive Team concerning orientation and in service education needs of patient care departments and coordination of hospital-wide education programs.

•         Oversees the monthly educational offerings in coordination with Education Manager, department directors and others as needs are assessed and planned. Ensures that calendar of events is published and distributed.

•         Oversees annual house-wide education to meet regulatory requirements and to ensure a safe environment for patients, visitors, and staff. Oversees maintenance of statistics of employees’ education completion utilizing electronic software.

•         Oversees the development of continuing education programs following the Florida State Board of Nursing, Radiology, Respiratory, Laboratory and Social Work provider requirements.

•         Maintains current provider number for Nursing, Radiology, Respiratory, Laboratory, and Social Work.

•         Assures qualified faculty is selected for educational programs.  Assures all programs are reported to CE Broker as required by Florida Law.

•         Oversees affiliation agreements with colleges, universities and other health education programs to ensure that all requirements for student clinical rotations are met.  Oversees orientation of all students prior to clinical rotation.

•         Reviews evaluation of all educational programs, revising as needed to enhance customer satisfaction.

•         Oversees the coordination of ACLS/BLS training for all qualified FHMMC personnel, and community healthcare personnel.

•         Oversees the management of the Education Department resources, including but not limited to the education classrooms, computer training rooms, Simulation Room ALCS/BLS training    rooms and all A-V equipment.

•         Directs development and maintenance of competency reviews used to assess hospital staff, to include age-specific and performance competency formats in collaboration with Human Resources.

•         Oversees the coordination of TJC & CARF Survey activities.

•         Ensures continual survey readiness throughout the organization

•         Directs interim progress reports for TJC & CARF , submitting within the specified time-frame.

•         Provides on-going information and education regarding TJC & CARF standards and requirements to   Medical Staff and hospital staff and management.

•         Acts as a liaison between the organization and TJC & CARF

•         Facilitates the regional clinical effectiveness and infection control council.

•         Represents clinical effectiveness as a region on the CNO/CMO council.

•         Directs the Patient Safety Organization requirements and implementation. 

•         Acts as the Patient Safety Officer. 


What will you need?

  • R.N. required. 
  • Seven to ten years’ healthcare administration/management experience, as well as a minimum of three to five years’ acute care clinical experience plus PI and TJC experience. 
  • Proven ability in areas of leadership/supervision, knowledge of legal aspects of healthcare, medical staff issues and PI principles required. 
  • Previous experience in preparing and presenting professional presentations required.
  • Advanced certification in Quality Improvement and/or Risk Management highly desired. 
Job Summary:

Plans, directs, and manages the activities of the Clinical Effectiveness Departments which include Performance Improvement, Infection Control Department, Risk Management and Education Departments.  Responsible for the preparation for and performance of surveys from external agencies such as The Joint Commission (TJC) and AHCA.    Oversees establishment of policies, procedures, standards and departmental objectives.  Acts as a liaison to the medical staff, administration, all hospital departments and committees to carry out all functions related to these areas.  Assures that the staff adheres to the Florida Hospital Corporate Compliance Plan and to the rules and standards of TJC and other applicable Federal, State and local regulatory and/or accrediting agencies.  Also oversees the Risk Management Program for loss prevention and claims control (according to federal, state, and local requirements) to meet the needs of all units of FH East Florida Region’s integrated healthcare delivery system. Also oversees the activities and personnel in the Education Department of Florida Hospital East Region.

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

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